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GENERATOR'S ENVIRONMENTAL MEDIA PROFILE SHEET <br /> INSTRUCTIONS: Please answer each question as completely as possible by circling"YES"or"NO", checking the appropriate boxes, <br /> filling in the blanks,or attaching additional sheets as necessary. An ink pen,typewriter or computer must be used. The Generator or <br /> Authorized Representative(agent)must sign the form. If the media changes or future analyses differ from what was submitted,Bucklen <br /> Equipment Company must be notified within 24 hours Signed Originals must follow fax or email copies. <br /> A. GENERATOR INFORMATION <br /> Generator/Transporter Name: Generator <br /> (REQUIRED) Contact: <br /> (REQUIRED) <br /> Business Address: Generator Title: <br /> (REQUIRED) <br /> Generator Email: <br /> (REQUIRED) <br /> Phone : Fax: <br /> B. ENVIRONMENTAL MEDIA INFORMATION (Where did this media originate?) <br /> Environmental Media Location: Describe the business at this location,including primary products or services: <br /> Process — Give a brief description of the process by which this media was generated: <br /> C. REGULATORY QUESTIONS (Based on 40 CFR Pan 261 and 6 CCR 1007.3 Part 261) Profile# <br /> 1. Does media contain a hazardous waste as defined by 6CCR 1007-3 Part 261 Sections 261.24 ❑YES ❑NO <br /> (D Code), Sections 261.31 (F Code),261.32(K Code),261.33 (P or U Codes)? <br /> 2. Is the media from an underground storage tank(UST)corrective action under 40 CFR Part ❑ YES ❑NO <br /> 280? (f`YES', also check `YES'on the following question) <br /> 3. Is the media from any of the following? •CERCLA project; • In response to a Compliance ❑ YES ❑NO <br /> Order; • Hazardous waste in another State; • Subject to Land Disposal Restrictions <br />